Complaint Form for Specific Performance of Contract in Georgia by zzj27078

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									                                                     CONTRACT
                                                 (Special Instruction)

This Contract is entered into by and between the (Local Health District), hereinafter referred to as the Local Lead
Agency and ____________________________________, including all employees, contractors, and
subcontractors, hereinafter referred to as the Special Instructor Provider.

Purpose of Contract: The purpose of this Contract is to establish the obligations, expectations, and relationship
between the Local Lead Agency and the Special Instruction Provider, and to ensure quality services are made
available to eligible children and their families according to Part C of the Individuals with Disabilities Education
Improvement Act of 2004 (IDEA), otherwise known as Part C or the Early Intervention Program for Infants and
Toddlers with Disabilities. In Georgia, the program is known as Babies Can’t Wait (BCW).

The intent of IDEA 2004 is for participating agencies and individual Special Instruction Providers to plan and
provide services collaboratively in order to deliver a comprehensive, coordinated, and quality program of services to
each eligible child and family. Interagency coordination and communication are essential to achieving
programmatic outcomes for children and families.

Definition of Special Instruction: Special Instruction is the “special education” component of Part C. It is above
and beyond education efforts aimed at typically developing children and thus must be developed and managed by
professionals with specialized education and experiences. Special Instruction is:

1.       The systematic planning and coordination of people, materials, and places to assist in identifying
         environments that offer learning opportunities in which thinking, moving, communicating, playing, and living
         appropriately with family and friends might be encouraged and promoted;

2.       Curriculum planning, including the coordination of people, materials, time, and place is built upon the
         unique strengths and priorities of the child and family. Curriculum and/or teaching content should be
         developmentally appropriate, culturally relevant, child and family directed, care provider responsive, play-
         based, and delivered in natural settings. The goals and objectives are determined through the use of
         functional, developmentally appropriate assessments and curriculum, systematic observation, and data
         collection that leads to achieving the outcomes and measuring successes as identified in the Individualized
         Family Service Plan (IFSP), including the Special Instruction plan;

3.       Working with the family and caregivers to support the child through approaches described above to
         enhance the child’s development and meet IFSP outcomes;

4.       To strengthen and reinforce the family’s knowledge and ability to enhance their child’s skill development
         within home and community, and through a systematic process that is responsive to cultural uniqueness,
         families should be provided with skills, support, resources as well as thorough and unbiased information.

The Special Instruction Provider has represented to the Local Lead Agency the ability to provide Special Instruction
for the purpose of implementing the IFSP, certifying that he or she meets all current state training, credentialing,
and/or licensure requirements, including continuing education requirements (Annex A, G), established as of the
effective date of this Contract.

Contract Effective Dates: This Contract has an effective beginning date of _____________________, and shall
remain in effect until June 30, _____.

The Special Instruction Provider is an independent contractor for whom no Federal or State Income Tax will be
deducted by the Local Lead Agency, and for whom no retirement benefits, workers' compensation protection,
survivor benefit insurance, group life insurance, vacation and sick leave, liability protection, and similar benefits
available to Local Lead Agency employees will accrue.


Special Instruction Contract Template              March 2006                                                  Page 1 of 5
The Special Instruction Provider will indemnify, defend, and save harmless the State and Local Board of Health, its
officers, agents, and employees from any and all claims and losses occurring or resulting to any person, firm, or
corporation who may be injured or damaged by the Special Instruction Provider in the performance of this Contract;
and any and all claims and losses accruing or resulting to any and all contractors, subcontractors, firms, or
corporations furnishing or supplying work, services, materials, or supplies to, on behalf of, or at the request of the
Special Instruction Provider, in connection with the performance of this Contract.

The Special Instruction Provider agrees to:

1.       Provide Special Instruction service(s) to eligible children and their families upon referral from the Local
         Lead Agency as set forth in the Individualized Family Service Plan (IFSP) and Special Instruction Plan;

2.       Participate in the development, review, and revision of IFSPs for children covered under this Contract in a
         timely and comprehensive manner;

3.       Participate in the completion of the Child Outcomes Summary Form for each child in order to collect
         federally-mandated outcome data.

4.       Provide quarterly attendance summaries to the Local Lead Agency/assigned Service Coordinator for each
         individual child/family receiving early intervention services;

5.       Attend the IFSP 6-month review and annual review and/or provide written progress summary for each
         individual child/family receiving early intervention services;

6.       Provide the Local Lead Agency with an invoice of charges for services to be reimbursed with Early
         Intervention Services Funds (EISF) less parent cost participation if applicable, by the 10th working day of
         the month following the service provision month. Invoices received by the Local Lead Agency in excess of
         six months beyond the date of service delivery shall not be honored. Services provided to Medicaid
         enrolled children shall be billed by the Special Instruction Provider directly to Affiliated Computer Services,
         Inc. (ACS) or the designated Care Management Organization for each child, if applicable. Services billed
         to private insurance shall be handled per the directions of the Local Lead Agency and the insurance carrier,
         if applicable;

7.       Meet and maintain all applicable and necessary standards and regulations for licensing, credentialing,
         program licensure, and funding requirements for services provided (Annex A, G) and the physical facilities
         (Annex C - ADA) in which services are made available as applicable;

8.       Meet and maintain all standards, guidelines, and program policies (Annex A, B, C, D, E, F, and G) as set
         forth by the Local Lead Agency and the State Lead Agency for Part C implementation in Georgia.
         Signature on this Contract acknowledges receipt of Annex A, B, C, D, E, F, G and acceptance of
         responsibility for adherence to the Annexes for the Special Instruction Provider;

9.       Provide all employees and subcontractors covered under this contract with policies and procedures,
         including complete copies of the BCW Standards and Implementation Manual, policy memos, Action
         Bulletins, relevant training notices, information about where/how to access Medicaid provider manuals, and
         other necessary items in a timely manner.

10.      Refrain at all times from divulging any information concerning the child and/or family to an unauthorized
         person without the informed, written consent of the parent(s);

11.      Notify the assigned Service Coordinator of any planned or recommended changes in the delivery of
         services to eligible children under this Contract prior to implementing any changes, including the
         termination of services prior to when the IFSP says the services will be terminated. This will allow the


Special Instruction Contract Template              March 2006                                                  Page 2 of 5
         assigned Service Coordinator to meet required procedural safeguards timelines for 10-calendar day written
         prior notice;

12.      Maintain accurate clinical records for a period of at least five years from discharge from early intervention
         services, and permit access to these records by the Local Lead Agency, State Lead Agency, the federal
         Departments of Health and Human Services and of Education or their assigns;

13.      Be in compliance with the Drug-Free Workplace Act of 1988 (34 CFR Part 85, Subpart F); Executive Order
         12549, Debarment and Suspension (34 CFR Part 85)(Annex F);

14.      Refer all potentially eligible children to the Babies Can’t Wait system point of entry within two days. (The
         Local Lead Agency determines eligibility for Babies Can’t Wait and performs intake services and other
         supportive services prior to the IFSP);

15.      Meet with the Local Lead Agency early intervention specialist at least quarterly to assure both
         programmatic and administrative quality assurance. The content of these meetings include:

         a)        Updates on State and local Special Instruction requirements and standards; and
         b)        Discussion of developmentally appropriate strategies and approaches for children receiving Special
                   Instruction.

16.      Implement (early intervention assistants) and/or develop (early interventionists/early intervention
         specialists) routine and ongoing Special Instruction plans that link the identified IFSP outcomes to specific,
         effective systematic instruction. See Annex A for further clarification of personnel roles;

17.      Provide Special Instruction contact notes for each child/family receiving Special Instruction on appropriate
         forms designated by the Local Lead Agency;

18.      Early intervention assistants will have at least one face-to-face meeting monthly with the Local Lead
         Agency early intervention specialist (or provider early intervention specialist) for the purpose of clinical
         supervision;

19.      Implement the use of universal safety precautions when providing direct service with each child to assist in
         controlling the spread of infectious disease;

20.      Attend and complete Project SCEIS training or successfully pass the PRAXIS II examination within two
         years of the initial Contract date or initial date of service with BCW, in accordance with BCW policy;

21.      Attend other training that is made mandatory by the State or Local Lead Agency, including continuing
         education requirements (Annex G);

22.      Refrain at all times from soliciting Babies Can't Wait-eligible families as clients and from selling products or
         fund raising with Babies Can't Wait-eligible families for personal profit or for an outside organization or
         business;

23.      Furnish the Local Lead Agency with certificates of insurance or written evidence of self-insurance covering:

         a.        Professional liability or services in this agreement with at least a limit of $1,000,000.
         b.        Statutory Worker’s Compensation, if applicable.
         c.        General liability insurance covering all operations and the indemnification clause in this contract;

24.      Complete a criminal records investigation procedure according to DHR policy (Annex D).



Special Instruction Contract Template               March 2006                                                  Page 3 of 5
The Local Lead Agency agrees to:

1.       Include the qualified Special Instruction Provider on the Service Provider Matrix for the early intervention
         service(s) they have agreed to provide for eligible children and their families. This information shall be
         reviewed at least annually by the Special Instruction Provider and shall be accurate and complete. Family
         members will be given options and choices of eligible providers who accept the family’s fund source
         through the presentation and review of the Service Provider Matrix prior to implementation of services on
         the IFSP;

2.       Reimburse the Special Instruction Provider at the hourly rate of (INSERT RATE HERE) less parent cost
         participation if applicable, upon presentation of a signed, dated invoice reflecting actual services provided
         and delivered to eligible children and their families as set forth in the IFSPs;

3.       Provide quarterly meetings by the Local Lead Agency early intervention specialist to assure administrative
         and programmatic quality assurance;

4.       Notify the Special Instruction Provider of scheduled IFSP review and revision team meetings, and solicit
         their involvement and input to this meeting through the child's assigned Service Coordinator;

5.       Provide clinical consultation activities to early interventionists and early intervention assistants (minimum of
         monthly face-to-face meetings) that assure curriculum methods and materials are in accordance with
         Babies Can’t Wait Evaluations and Assessments and the Special Instruction Plan as identified in the child’s
         IFSP;

6.       Respond (at least) verbally to all referrals within 3 working days of receipt of the referral, and provide to the
         original referral source information related to the disposition of the referral;

7.       Provide all appropriate policies and procedures, including complete copies of the BCW Standards and
         Implementation Manual, policy memos, Action Bulletins, relevant training notices and other necessary
         items in a timely manner.

The Special Instruction Provider and Local Lead Agency mutually agree to:

1.       Ensure that local, state, and federal funds accessed to support some or all of the services for an eligible
         child reflect written, informed parental consent and that federal or state early intervention (Part C) funds are
         utilized only when no other funds are available. Documentation of this payor of last resort requirement
         shall be reflected in the IFSP Meeting Notes and in the clinical record maintained by the child's assigned
         Service Coordinator;

2.       Ensure the provision of early intervention services using appropriately credentialed and/or licensed
         providers (Annex A, G), and maintain the integrity of the IFSP process through accurate and timely
         implementation of the services as mutually determined and agreed to by the IFSP Team, and consented to
         in writing by the child's parent(s). Special Instruction Providers must meet training requirements, including
         continuing education, established by the State and Local Lead Agency;

3.       Bill family members only for some or all of the early intervention services as mutually identified and agreed
         to in the IFSP, based upon completion of the Financial Analysis for Cost Participation. The Special
         Instruction Provider agrees to accept reimbursement from the Local Lead Agency for Babies Can't Wait, or
         other local, state, federal, or private funds as payment in full unless otherwise specified in writing in the
         child's IFSP. The Special Instruction Provider agrees to accept reimbursement from the Local Lead
         Agency as payment in full for evaluations/assessments authorized by the Local Lead Agency;

4.       Ensure that early intervention services are family-centered, provided in natural environments, and culturally
         competent. Family members have an integral and equal role in service planning, supporting the child's

Special Instruction Contract Template               March 2006                                                  Page 4 of 5
         participation in early intervention services, and meeting the outcomes identified in the IFSP. Ensure that
         early intervention services are provided based upon the identification of child and family strengths and
         desired skills to be acquired by each eligible infant and toddler in order to promote maximum inclusion and
         participation in home and community settings. Intervention must be integrated throughout activity settings
         and learning opportunities within locations where families typically spend time. Ensure that intervention
         focuses on working with and coaching families and caregivers to support each child achieve optimal
         participation and inclusion in home and community activities and settings;

5.       Ensure effective implementation of procedural safeguards for each eligible child and family; and each
         Special Instruction Provider shall ensure that family members are knowledgeable about the services being
         provided, and if applicable, transition activities within and from the Part C/Babies Can't Wait Program;

6.       Participate in the planning and development of individual IFSPs. Special Instruction Providers must ensure
         that all modifications to an existing IFSP are made through the child/family's assigned Service Coordinator
         and the IFSP process; and understand that they may not bill or receive reimbursement for services in
         excess of what is reflected on the IFSP, or terminate services for an eligible child without first notifying the
         child's assigned Service Coordinator prior to the anticipated date of service change so that the Service
         Coordinator has ample time to give the family 10 calendar day written prior notice;

7.       Participate in the routine monitoring and supervision of activities as set forth by the local and State lead
         agencies, including self-assessment, on-site monitoring, data collection and reporting obligations, record or
         chart audits, financial audits, complaint investigation, and consumer satisfaction surveys.


Conflict of Interest: No individual Special Instruction Provider of early intervention service(s) may also be the
assigned Service Coordinator for an individual child. If the assigned Service Coordinator for an individual child is
employed by the same agency that provides some or all of the early intervention services listed in the IFSP, the
Local Lead Agency Early Intervention Coordinator shall review all service activity and revisions prior to
implementation and changes to the IFSP.

Termination of this Contract: This Contract may be terminated by the Local Lead Agency, in writing, without
cause or for convenience with thirty (30) day prior written notice of the intent to terminate or cancel the provisions
set forth in this Contract. This Contract may be terminated by the Contractor, in writing, without cause or for
convenience with sixty (60) day prior written notice of the intent to terminate the Contract.

This Contract may be terminated by the Local Lead Agency at any time for failure by the Special Instruction
Provider to perform any of the obligations and provisions set forth in this Contract. This termination will be in
writing, by the Local Lead Agency, and will specify the reason for termination and the termination date.

This contract includes Annexes as listed below, which are hereto attached:

        Annex A             BCW Standards and Implementation Manual, including Fiscal Policies
        Annex B             Procedural Safeguards Requirements and Technical Assistance Guide
        Annex C             Individuals with Disabilities Education Improvement Act of 2004; Part C Regulations; ADA
        Annex D             DHR Policy and Procedures - Contractor Criminal Record Investigations Procedure
        Annex E             Other Local Lead Agency documents (forms, etc)
        Annex F             Drug-Free Workplace Act of 1988; Executive Order 12549 Debarment and Suspension
        Annex G             Continuing Education Policy
        Annex H             Family Outcomes Survey, Child Outcomes Summary Form, Frequently Asked Questions
                             about Child and Family Outcomes in BCW

IN WITNESS WHEREOF, THE PARTIES HAVE HEREUNTO AFFIXED THEIR SIGNATURES.



Special Instruction Contract Template                March 2006                                                Page 5 of 5
_______________________________________________      _____/_____/_____
District Health Director                                    Date



_______________________________________________      _____/_____/_____
Special Instruction Provider                                Date




Special Instruction Contract Template   March 2006                       Page 6 of 5

								
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